Chapter 23 Health & Physical Assessment In Nursing 3rd Edition

Chapter 23  Health & Physical Assessment In Nursing 3rd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
During the examination of an older adult male client the nurse notes thin, gray pubic hairs and a scrotal sac that hangs significantly lower than the penis. Which action by the nurse is the most appropriate?
1. Document the findings as normal.
2. Inform the client that he is no longer fertile.
3. Notify the healthcare provider of the findings.
4. Ask the client about his sexual practices.
Correct Answer: 1
Rationale 1: The older adult male begins to demonstrate thinning and graying of the pubic hair. The penis and testicles begin to diminish in size and the scrotum hangs lower.
Rationale 2: Sperm production in the middle aged and older man is reduced but there is still adequate sperm production to father children.
Rationale 3: The findings are normal and do now warrant notification of the healthcare provider.
Rationale 4: The sexual practices of the client are not impacted by the findings. Inquiry into them is not indicated at this time.
Global Rationale: According to Tanner’s Maturation Stages in the male, the findings in this situation are appropriate for the older adult male client. Although sperm production does decline during middle age, the presence of viable sperm in the older adult male contradicts infertility. No further subjective information is required by the nurse, and the healthcare provider does not need notification.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 23.1: Describe the anatomy and physiology of the male reproductive system.
MNL Learning Outcome: 14.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 611

Question 2
Type: MCSA
During the examination of a male client who has not been circumcised, the nurse attempts to retract the foreskin of the penis, but skin is very tight and cannot be pulled back. Based on this data, which condition does the nurse anticipate for this client?
1. Urethral stricture.
2. Paraphimosis.
3. Urethritis.
4. Phimosis.
Correct Answer: 4
Rationale 1: Urethral strictures would be suspected in the event of voiding problems or if a pinpoint size meatus opening was noted, not an inability to retract the foreskin over the glans penis.
Rationale 2: Paraphimosis is a condition in which the foreskin cannot be moved back over the glans penis once it has been retracted.
Rationale 3: Urethritis manifests with symptoms including redness and edema around the glans and foreskin, eversion of the urethral mucosa, and drainage.
Rationale 4: Phimosis refers to a condition in which the foreskin cannot be moved back over the glans penis.
Global Rationale: Phimosis is a condition in which the foreskin is too tight to retract over the glans penis. Paraphimosis is a condition in which the foreskin cannot be moved back over the glans penis once retracted. Urethritis is a condition in which the urethra is infected or inflamed. Signs of urethritis include redness and edema around the glans and foreskin, eversion of urethral mucosa, and drainage. A urethral stricture is suspected if the urinary meatus is pinpoint size.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 23.1: Describe the anatomy and physiology of the male reproductive system.
MNL Learning Outcome: 14.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 625

Question 3
Type: MCSA
The nurse is interviewing a male client who states “I feel like I have a bag of worms in my scrotum.” Based on this data, which condition does the nurse suspect?
1. Orchitis.
2. Varicocele.
3. Epididymitis.
4. Inguinal Hernia.
Correct Answer: 2
Rationale 1: Orchitis refers to a swelling and inflammation of the testicles.
Rationale 2: A varicocele is a distention of the spermatic cord and may be described as a “bag of worms.”
Rationale 3: Epididymitis is an inflammatory condition of the epididymis.
Rationale 4: An inguinal hernia feels like a bulge or mass upon palpation of the inguinal canal, which indicates a protrusion of the intestine into the groin region.
Global Rationale: A varicocele is a distention of the spermatic cord and often is described as “a bag of worms.” Swelling or inflammation of the testicles is referred to as orchitis. Epididymitis is an inflammatory condition of the epididymis. An inguinal hernia feels like a bulge or mass upon palpation of the inguinal canal, which indicates a protrusion of the intestine into the groin region.
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 23.1: Describe the anatomy and physiology of the male reproductive system.
MNL Learning Outcome: 14.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 629

Question 4
Type: MCMA
When caring for a male client scheduled for a prostatectomy due to cancer, which data would the nurse expect for a client with this condition data?
Standard Text: Select all that apply.
1. Enlargement of the scrotal sac.
2. Pyuria.
3. Increase in prostatic specific antigen (PSA).
4. Dribbling of urine.
5. Difficulty in initiating urine stream.
Correct Answer: 3, 4, 5
Rationale 1: The scrotal sac will not be enlarged with a diagnosis for prostate cancer. Scrotal sac enlargement may be noted in the presence of inflammation of the testicles or the epididymis.
Rationale 2: Pyruia refers to pus in the urine. Pus in the urine is not consistent with the presence of prostate cancer.
Rationale 3: Low levels of prostatic specific antigen are present in normal, healthy men. Laboratory values for the PSA will be elevated in the presence of prostate cancer.
Rationale 4: The dribbling of urine may be seen with prostate cancer. Dribbling will occur in the presence of prostate enlargement.
Rationale 5: Prostate enlargement as seen in malignant conditions may result in the client experiencing difficulty in initiating the urine stream.
Global Rationale: Low levels of prostatic specific antigen (PAS) are present in normal, healthy men. PSA levels are used to assess for the presence of prostate cancer. Laboratory values for the PSA will be elevated in the presence of prostate cancer. Conditions of the prostate gland may result in urinary changes. The dribbling of urine may be seen with prostate cancer. Dribbling or difficulty starting the urine stream may be seen in the presence of prostate enlargement. The scrotal sac of the client diagnosed with prostate cancer would not be enlarged. The prostate is located on each side of the male urethra just below the bladder. It is not anatomically near the scrotal sac. Pyruia refers to pus in the urine. Pus in the urine is not consistent with a diagnosis of prostate cancer.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 23.1: Describe the anatomy and physiology of the male reproductive system.
MNL Learning Outcome: 14.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 612

Question 5
Type: MCSA
While performing prostate palpation, the nurse notes that the client expresses severe tenderness and discomfort during the procedure. Based on this data, which condition does the nurse suspect?
1. Prostate cancer.
2. Prostatitis.
3. Enlargement of the prostate.
4. Urinary tract infection.
Correct Answer: 2
Rationale 1: The presence of extreme hardness or nodules is characteristic of prostate cancer.
Rationale 2: The prostate should feel smooth, firm, or rubbery, and extend no larger than one centimeter into the rectal area. This exam should not cause tenderness, which is an indication of inflammation.
Rationale 3: Enlargement of the prostate will cause urinary tract symptoms such as difficulty in starting a stream, or dribbling of urine.
Rationale 4: Urinary tract infections will cause painful and frequent urination.
Global Rationale: Upon examination, the prostate should feel smooth, firm, or rubbery, and extend no larger than one centimeter into the rectal area. This exam should not cause tenderness, which is an indication of inflammation. The presence of extreme hardness or nodules is characteristic of prostate cancer. Enlargement of the prostate will cause urinary tract symptoms such as difficulty in starting a stream, or dribbling of urine. Urinary tract infections will cause painful and frequent urination.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care.
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 23.1: Describe the anatomy and physiology of the male reproductive system.
MNL Learning Outcome: 14.1.1. Correlate the anatomy and physiology to the landmarks that direct physical assessment.
Page Number: p. 633